ORIGINAL RESEARCH
published: 10 January 2019
Edited by:
Nicola Cellini,
Universit degli Studi di Padova, Italy
Reviewed by:
Louise Beattie,
University of Glasgow,
United Kingdom
Melinda Jackson,
RMIT University, Australia
*Correspondence:
Bernd Feige
bernd.feige@uniklinik-freiburg.de
Specialty section:
This article was submitted to
Emotion Science,
a section of the journal
Frontiers in Psychology
Received: 07 September 2018
Accepted: 17 December 2018
Published: 10 January 2019
Citation:
Feige B, Baumgartner B, Meyer D and
Riemann D (2019) The Relationship
Between PSG and Morning/Evening
Emotional Parameters in Patients With
Insomnia Disorder and Good
Sleepers. Front. Psychol. 9:2712.
doi: 10.3389/fpsyg.2018.02712
Frontiers in Psychology | www.frontiersin.org
doi: 10.3389/fpsyg.2018.02712
The Relationship Between PSG and
Morning/Evening Emotional
Parameters in Patients With Insomnia
Disorder and Good Sleepers
Bernd Feige*, Blanda Baumgartner, Dora Meyer and Dieter Riemann
Department of Clinical Psychology and Psychophysiology, Medical Center–University of Freiburg, Faculty of Medicine,
University of Freiburg, Freiburg, Germany
Objectives and Introduction: It is as yet unclear how polysomnographically determined
sleep parameters determine emotional well-being both generally and particularly in
patients with Insomnia Disorder (ID). ID is a frequent and disabling health condition
associated with both day- and nighttime hyperarousal, linked to negative sleep-related
ruminations as a cognitive component. Information on the immediate influence of
objective sleep quality on emotional parameters is important for therapeutic approaches.
Methods: The relationship between objective sleep parameters and two emotional
questionnaire items obtained both for evening and morning, relaxation and emotional
balance, was determined for both sleep lab nights in 161 ID patients and 161 age and
gender matched good sleepers (retrospective sample from the Freiburg data base, 98
female, 63 male in each group, age ID: 42.16 ± 11.55, GSC: 41.91 ± 11.30 years).
Multivariate mixed effects analysis, corrected for global influences of group, age and
first/second night, was employed to determine between- and within-subject influences
of sleep and emotional parameters.
Results: Main effects: Within-subject, relaxation in the evening was strongly associated
with sleep efficiency, REM latency and low arousal index in NREM sleep. No such
influence was significant for emotional balance. Also between subjects, evening
relaxation was related to increased sleep efficiency. Group interactions: Patients with
larger relaxation values in the evening showed a larger reduction of the number of wake
periods and the awakening index in NREM sleep than GSC subjects.
Discussion: Unexpectedly, no general influence of emotional balance on sleep was
found. The subjective feeling of relaxation, however, was associated with sleep efficiency,
REM latency and low NREM sleep arousal index. While the first association may be
obvious, a direct link to REM latency and NREM arousal index has not previously been
shown. We could also directly observe that the number of wake periods in the PSG
is more strongly influenced by evening relaxation in ID patients than in good sleepers,
asserting the importance of sleep perception and attitude toward sleep in the therapeutic
process.
Keywords: PSG (Polysomnography), insomnia, emotion, questionnaire, good sleepers
1 January 2019 | Volume 9 | Article 2712
Feige et al.
INTRODUCTION
Theories of chronic insomnia emphasize the role of
cognitive, emotional, and physiological hyperarousal for its
development and maintenance (Harvey, 2002; Espie et al.,
2006). Own work (Riemann et al., 2010, 2011, 2012, 2015)
summarized that hyperarousal processes seem to play a key
role in its pathophysiology. Autonomous, neuroendocrine,
neuroimmunological, electrophysiological, neuroimaging, and
psychological studies deliver converging evidence for increased
levels of arousal in ID without comorbidity compared to good
sleepers. Corresponding to the subjective experience of patients
with insomnia having difficulties to “shut down” or to disengage
from wakefulness (especially when trying to sleep), physiological
data reflect increased levels of arousal both during day- and
nighttime compared to good sleepers. It is assumed that the
permanent hyperarousal in chronic insomnia—linked to habit
formation or alternatively to an (epi-) genetic lack in the ability to
down-regulate arousal (e.g., Palagini et al., 2014)—is triggered by
stressful life events and maintained by sleep-preventing learned
associations and maladaptive coping strategies (neurocognitive
model of insomnia as formulated by Perlis et al., 1997).
Little is known on the concrete relationship between cognitive
and emotional state in the evening and in the morning and
objective measures of sleep. It is well-known that in Insomnia
Disorder (ID) subjective sleep perception is often worse than
objective sleep measures suggest, while healthy subjects tend to
overestimate their sleep time (Carskadon et al., 1976; Frankel
et al., 1976; Edinger and Fins, 1995; Means et al., 2003). This bad
perception of sleep has been linked to qualitatively different REM
sleep (Feige et al., 2008, 2018; Riemann et al., 2012). The studies
on sleep perception are based upon subjective assessments in the
morning after a sleep night. When assessing state variables such
as cognitive and emotional state, however, two different aspects
are equally important: The state at bedtime (evening) and the
state change from evening to morning. The state at bedtime may
influence sleep in the successive night, while the state change
across the night may be influenced by the objective characteristics
of sleep.
Sleep and affective phenomena have been linked before.
People suffering from ID often do not feel refreshed and
feel impaired in relevant areas of life as stated in DSM-IV
(American Psychiatric Association, 2000) and DSM-5 (American
Psychiatric Association, 2013). They also report worse mood than
healthy controls and negative mood in ID correlates positively
with subjective sleep latency (Buysse et al., 2007). Additionally,
epidemiological studies show that insomnia increases the risk
of developing depression (Baglioni et al., 2011) and anxiety
disorders (Morphy et al., 2007; Neckelmann et al., 2007). A model
by Walker (2009) allows to explain this relationship between
sleep and affective disorders. He suggests that sleep plays a crucial
role in emotion regulation and that memories and emotion
are disentangled during sleep. If this disentanglement does
not work properly, the risk of developing chronic anxiety and
depression increases. Wassing et al. (2016) examined correlations
between REM sleep disruption, hyperarousal, insomnia, and
the resolution of emotional distress. They found a positive
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PSG and Emotional Parameters in Insomnia
correlation between insomnia severity, restless REM sleep and
duration of emotional distress (specifically shame) overnight.
In the current study we aimed at the relationship between
objective sleep parameters and more general emotional states as
rated using the SF-A sleep questionnaire (Schlaffragebogen-A,
Görtelmeyer, 1981).
This questionnaire is similar to a sleep diary in that it contains
evening and morning items filled for each night. It measures
subjective quality of sleep, feeling recuperated after sleep,
psychological balance before going to sleep and psychosomatic
symptoms during sleep. In addition, identical evening and
morning items are available for relaxation and emotional balance.
Combined with sleep laboratory examinations, it therefore allows
to directly assess the relationship between the latter items—
both state in the evening and change across the night with PSG
(polysomnographic) parameters. Relaxation can be viewed as
inverse arousal, thereby providing a link to the hyperarousal
theories of insomnia. Emotional balance may provide an
assessment of the importance of emotional processes.
Assessing two nights of every subject in addition allows
us to discriminate between- and within-subject, i.e., trait- and
state- like influences: Subjects generally reporting low emotional
balance may, for example, show certain sleep characteristics by
trait; this does not necessarily mean that targeting emotional
balance therapeutically will change sleep as well. A within-subject
relationship (between the nights) however, provides a better hint
at a possible therapeutic pathway. At the same time we can
control for a first night effect, which itself is thought to result
from elevated arousal during the first night in a sleep laboratory
(Agnew et al., 1966; Wauquier et al., 1991).
As most studies on sleep and emotion refer to subjective sleep
data, the aim of this study was to explore potential relationships
between subjective emotional states (relaxation and emotional
balance) and objective sleep patterns in ID ad GSC using data
from first and second night’s sleep assessed at the sleep laboratory.
MATERIALS AND METHODS
Participants and Procedure
Patients With Insomnia Disorder (ID)
This comparative observational study was based on a chart
and data review of clinical patients with insomnia complaints
evaluated between 1995 and 2012 at the sleep center of
the Department of Psychiatry and Psychotherapy, Freiburg
University Medical Center. During this period, 304 patients had
been examined for two nights and diagnosed with Insomnia
Disorder (ID; to ensure continuity, the diagnosis was primary
insomnia after DSM-IV before DSM-5 and ID after DSM-5
thereafter, with exclusion criteria ensuring that this corresponded
to primary insomnia after DSM-IV).
All patients had been referred from their primary care
physician or medical specialist for evaluation of their sleep
complaint. Two weeks before consultation in our outpatient
sleep disorders clinic, patients received a questionnaire screening
package by mail which included, among others, the Beck
Depression Inventory (BDI, Beck and Steer, 1987; German
version by Hautzinger et al., 1994) and the Pittsburgh Sleep
2 January 2019 | Volume 9 | Article 2712
Feige et al.
Quality Index (PSQI, Buysse et al., 1989; German version by
Riemann and Backhaus, 1996, see below). During the 1-h intake
interview in the outpatient facility, patients were interviewed
about: onset and duration of insomnia, sleep habits as well
as history of medical illnesses, psychiatric disorders, use of
medication, drugs, tobacco and alcohol, sleep disorders in first
degree relatives (parents, siblings, and children) as well as
education and social background.
A preliminary diagnosis was given on the basis of this
interview and a decision was made about the necessity of a sleep
laboratory examination (e.g., in case of: chronicity, persistence
of insomnia despite adequate therapy, suspicion of possible
underlying organic causes). Patients were then scheduled for
a PSG evaluation approximately 4 to 8 weeks after the first
outpatient contact.
During their 2-day stay in the sleep center, all patients
underwent a thorough physical, psychiatric (repeating
the interview taken 4–8 weeks earlier) and neurological
examination, routine blood tests (blood cell count, liver, renal,
and thyroid function), ECG, EEG, and urine drug screen
(opiates, barbiturates, benzodiazepines, amphetamines and
cannabis, and viral/bacterial infection).
Exclusion criteria for the present data analysis were: Presence
of any other sleep disorder (e.g., sleep apnea syndrome,
restless-legs syndrome, narcolepsy, circadian rhythm disorders,
organic or psychiatric insomnia as defined by DSM-IV); A
sleep apnea-/PLMS (period leg movements in sleep)-index with
arousal ≥ 5.0/TST (total sleep time); Clinically relevant medical
or neurological disorders or a positive urine drug screen;
Consumption of hypnotic medication or medication known to
affect sleep in the 2 weeks before or during sleep laboratory
examination; Pregnancy; Any history of psychiatric disorder, of
serious medical illness (e.g., hepatitis), substance abuse or shift
work in the past.
During the two nights of sleep laboratory examinations
patients had to refrain from alcohol. Decaffeinated coffee was
only allowed in the morning for breakfast (maximum: two cups).
179 patients with confirmed insomnia disorder (ID) fulfilling
the in- and exclusion criteria were finally eligible for statistical
analysis.
Good Sleeper Controls (GSC)
One hundred and ninety-eight good sleeper controls (GSC) were
available for the current study. They were selected retrospectively
from our database of healthy subjects who participated in healthy
volunteer studies of our sleep center. Control subjects underwent
the same routine procedure of examinations as ID patients
to ensure physical and psychiatric health. In addition to the
exclusion criteria applying to the patients, good subjective sleep
quality was required to be reflected in a PSQI sum score below 6.
Medical problems including sleep apnea or restless legs syndrome
were excluded. Written informed consent was obtained from all
healthy subjects prior to the investigation in the sleep center.
Matched Groups for Final Analysis
From the ID and GSC groups described above, 161 ID patients
and 161 GSC subjects could be matched using automated pair
matching for gender and mean age within each gender group.
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PSG and Emotional Parameters in Insomnia
The final matched sample consisted of 63 men and 98 women
of each group aged 42.16 ± 11.55 years (ID, 19–67 years) and
41.91 ± 11.30 years (GSC, 20–69 years). The age distribution did
not differ (Wilcoxon W = 13122, p = 0.847).
Polysomnography
All polysomnographic investigations were carried out using a
standardized procedure. All subjects underwent two consecutive
nights of PSG sleep monitoring. Sleep was recorded on 14-
channel Nihon-Kohden EEG-polysomnographs for 8 h from
“lights out” (23:00 h) until “lights on” (7:00 h) and digitized at a
rate of 200 Hz. All recordings included EEG (C3A2; C4A1), EOG
(horizontal and vertical) and EMG (submental) and were scored
visually by experienced raters according to Rechtschaffen and
Kales (1968) criteria. Inter-rater reliability is regularly evaluated
and ensured to be above 0.9 as part of laboratory routine. During
the first night, all subjects were screened for apneas and periodic
leg movements by monitoring abdominal and thoracic effort,
nasal airflow, oxymetry, and bilateral tibialis anterior EMG.
Sleep recordings were evaluated for the following parameters
of sleep continuity and architecture: total sleep time (TST), sleep
efficiency (SEI): ratio of TST to time in bed (TIB) x 100%;
sleep onset latency (SOL): time from lights out until sleep onset
(defined as first epoch of stage N2). Arousals were analyzed
according to the criteria of the American Sleep Disorders
Association (Sleep Disorders Atlas Task Force of the American
Sleep Disorders Association, 1992). The arousal index is the
number of arousals per hour. We evaluated both the arousal
index within TST and sleep stage specific indices (stage N2,
REM). In addition, short awakenings within N2 and REM sleep
were captured accordingly as awakening index. Sleep architecture
variables included: amounts of stages wake (W), N1, N2, slow
wave sleep (SWS), and REM expressed as percentage of sleep
period time (SPT: time from sleep onset until final awakening).
REM sleep variables were REM latency (time from sleep onset
until the first epoch of REM sleep, possible wake time not
counted) and REM density, calculated as the ratio of 3 s REM
mini-epochs including rapid eye movements (REMs) to the total
amount of REM mini-epochs x 100%. REMs were defined using
separate vertical and horizontal EOG traces, requiring a steepness
of excursions of at least 70 µV/s.
Subjective Sleep Scales
The PSQI (Buysse et al., 1989; Riemann et al., 1996) assesses sleep
habits and quality in the preceding 2 weeks. Variables reported
for group descriptives are the subjectively reported sleep onset
latency, total sleep time, and (derived) sleep efficiency as well
as the PSQI sum score (ranging from 0 to 21, highest values
denoting severely impaired sleep).
The SF-A (Schlaffragebogen-A, Görtelmeyer, 1981, in its
revised form Görtelmeyer, 2011) captures subjective aspects of
sleep in the preceding night. It was administered in the morning
after each sleep recording, after subjects were awake for some
minutes. The questionnaire contains subjective estimates of wake
times (SOL and wake after sleep onset, WASO) as well as the
frequency of awakenings. Of the additional 5-level items (values
1-5) asked regarding to experiences in the evening prior to sleep
and in the morning after sleep, “relaxation” and “emotional
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Feige et al. PSG and Emotional Parameters in Insomnia

balance” are formulated identically for evening and morning
and therefore can be directly compared. Both items are part
of the SF-A factor scales “psychological balancedness in the
evening” and “feeling of recuperation in the morning. ”The
German term “Ausgeglichenheit” translated here as “balance”
or “balancedness” means absence of disturbing thoughts or
emotions and could also be translated as “calmness of the mind.
”The questions are “how relaxed/how emotionally balanced did
you/do you feel”. The relationship of these two variables with
PSG sleep is the major topic of this study. Descriptive subjective
sleep quality data for both groups is given in Table 1.
Statistical Analysis
Two-tailed non-parametric Wilcoxon tests were employed to
ensure that the groups did not systematically differ in age.
χ 2 tests were used to compare dichotomous variables between
groups. For descriptive purposes, means and standard deviations
were calculated for PSG and subjective sleep parameters. Group
differences (ID vs. GSC), night (first, second) and age effects were
assessed using mixed-effects MANOVAs with between-subject
factor GROUP and covariate AGE as well as within-subject factor
NIGHT. Multivariate statistics were based on Wilk’s Lambda. P <
0.05 was considered to be significant, proceeding from significant
multivariate effects to univariate effects of the same independent
variable. For univariate effects, we report F and p values as well as
B values (betas) of the linear model, i.e., coefficients or differences
between factor levels. For the NIGHT effect this is Night2-Night1
and for the GROUP effect ID-GSC.
For the main analysis of the influence of relaxation and
emotional balance which were assessed before and after each
night, mixed-effects MANOVAS were used with between-subject
factor GROUP and covariate AGE as well as within-subject
factor NIGHT and covariates morning values as well as changes
across the night (morning-evening) of relaxation and emotional
balance. Only the terms involving the target variables alone and
their GROUP interactions are reported. The remaining terms are
regarded as nuisance effects in this analysis. This pertains to the
terms identical to the previous, more descriptive model (Table 2)
and the NIGHT interactions.
The rationale for using evening scores and differences across
the night instead of evening and morning scores was that evening
and morning scores can be expected to be related to some
degree; also, the difference across the night can be hypothesized
to be determined by some property of the intervening sleep. If
evening and morning scores were entered independently into an
analysis, this important change aspect would be reflected only in
an interaction term of these covariates, rendering analysis and
conclusions more complex.
All statistical analyses were performed using the statistical
software suite “R” version 3.5.1 (R Core Team, 2018).
RESULTS
Main Effects for Group, Night, and Age
Table 2 shows the more descriptive MANOVAs separately for the
PSG variables and the target variables relaxation and emotional
balance. For PSG, multivariate effects are seen for GROUP,
NIGHT, and AGE but not NIGHT x GROUP. The GROUP
effect shows the typical reductions in total sleep time (TST)
and sleep efficiency index (SEI) in the ID group as well as an
increased awakening index in NREM sleep. The NIGHT effect
shows reduced sleep onset latency (SOL), increased TST and SEI,
reduced number of wake periods (NWP) as well as arousal and
awakening indices in NREM sleep (AI/N and AWI/N) in the
second relative to the first night. Increased AGE is associated
with reduced TST and SEI, increased NWP as well as increases
in arousal and awakening indices in both NREM and REM sleep.

TABLE 1 | Descriptives of subjective sleep quality for both groups.

GSC ID Group Age

Mean ± SD Mean ± SD B F p B F p

Multivariate statistics 0.36 0.000 0.85 0.000

(Wilk’s Lambda)
PSQI SOL 14.25 ± 10.93 41.89 ± 47.50 27.39 42.11 0.000 0.16 0.71 0.401
TST 431.69 ± 56.28 302.17 ± 88.38 −126.30 216.97 0.000 −1.45 13.99 0.000
SEI 87.79 ± 25.03 60.31 ± 26.19 −27.86 242.58 0.000 −0.16 4.20 0.041
PSQI sum score 3.68 ± 2.12 10.96 ± 3.37 7.23 461.27 0.000 0.02 2.70 0.101
SF-A SOL 11.35 ± 11.32 22.20 ± 17.90 10.86 36.50 0.000 0.08 1.00 0.317
TST 452.92 ± 29.85 408.01 ± 61.61 −44.95 58.30 0.000 −0.29 1.20 0.274
SEI 94.25 ± 6.13 84.90 ± 12.80 −9.35 58.43 0.000 −0.05 1.01 0.315
SQ 3.58 ± 0.67 2.90 ± 0.74 −0.69 67.28 0.000 −0.01 3.03 0.083
R_MOR 3.60 ± 0.72 2.80 ± 0.82 −0.84 82.36 0.000 0.01 5.35 0.021
WB_EVE 3.92 ± 0.64 3.53 ± 0.66 −0.41 27.67 0.000 0.00 0.00 0.964
EX_EVE 2.60 ± 0.67 2.92 ± 0.70 0.29 11.88 0.001 −0.01 2.99 0.085
PS 1.49 ± 0.48 1.87 ± 0.47 0.38 52.92 0.000 0.01 13.50 0.000

The SF-A of the second night is used. For the Group effect, B=ID-GSC. GSC, Good Sleeper Controls; ID Patients with Insomnia Disorder; PSQI, Pittsburgh Sleep Quality Index; min,
Minutes; SOL, Sleep Onset Latency; TST, Total Sleep Time; SEI, Sleep Efficiency Index %; SF-A, Schlaffragebogen-A; SQ, Sleep Quality; R_MOR, Recovery in the morning; WB_EVE,
Wellbeing in the evening; EX_EVE, Exhaustion in the evening; PS, Psychosomatic Symptoms. p values below p = 0.05 are set in bold font.

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 TABLE 2 | Characteristics of PSG data and the variables on relaxation and emotional balance.

Adaptation night Baseline night Effects

Feige et al.

GSC ID GSC ID Group Night Night x Group Age

Mean ± SD Mean ± SD Mean ± SD Mean ± SD B F p B F p B F p B F p

Multivariate statistics 0.84 0.000 0.55 0.000 0.96 0.714 0.66 0.000
(Wilk’s Lambda)
SOL (min) 22.87 ± 19.86 25.39 ± 22.10 17.44 ± 15.38 15.85 ± 11.97 0.45 0.08 0.778 −5.43 45.49 0.000 −4.11 3.42 0.065 0.05 0.55 0.461
TST (min) 391.71 ± 51.29 361.24 ± 64.06 419.22 ± 33.04 396.90 ± 47.24 −26.08 33.75 0.000 27.51 125.10 0.000 8.15 2.08 0.150 −1.29 41.57 0.000
SEI (%) 81.61 ± 10.58 75.35 ± 13.27 87.33 ± 6.85 82.67 ± 9.81 −5.40 33.71 0.000 5.72 125.86 0.000 1.61 1.92 0.167 −0.27 42.61 0.000
NWP 29.27 ± 13.80 31.68 ± 14.95 27.50 ± 14.34 29.56 ± 14.57 2.14 2.65 0.105 −1.77 8.41 0.004 −0.35 0.07 0.795 0.39 42.72 0.000

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W (%SPT) 12.95 ± 9.08 17.92 ± 11.92 8.49 ± 5.61 12.68 ± 9.39 4.52 30.85 0.000 −4.46 83.18 0.000 −0.78 0.54 0.461 0.26 50.73 0.000
N1 (%SPT) 9.30 ± 4.92 9.98 ± 4.92 8.02 ± 4.65 8.64 ± 4.22 0.62 2.05 0.153 −1.28 44.32 0.000 −0.06 0.02 0.877 0.14 47.00 0.000
N2 (%SPT) 51.96 ± 8.43 50.39 ± 9.51 54.93 ± 7.24 53.04 ± 9.12 −1.71 4.04 0.045 2.98 44.52 0.000 −0.32 0.14 0.706 −0.07 3.38 0.067
N3 (%SPT) 7.02 ± 6.55 5.05 ± 5.81 7.97 ± 6.78 6.24 ± 7.06 −1.80 8.01 0.005 0.94 26.04 0.000 0.24 0.33 0.566 −0.20 50.39 0.000
REM (%SPT) 18.44 ± 5.44 16.55 ± 5.44 20.39 ± 4.91 19.25 ± 4.57 −1.49 10.10 0.002 1.94 71.57 0.000 0.76 1.90 0.169 −0.12 31.20 0.000
REML (min) 101.51 ± 48.39 107.84 ± 60.51 76.50 ± 33.55 72.94 ± 30.44 1.34 0.13 0.719 −25.01 86.81 0.000 −9.89 2.37 0.125 0.16 0.88 0.348
REMD (%) 24.96 ± 7.51 25.97 ± 8.77 25.36 ± 7.83 26.94 ± 7.41 1.30 2.61 0.107 0.40 3.54 0.061 0.58 0.63 0.429 −0.04 1.32 0.252
AI/REM 18.19 ± 9.32 18.50 ± 9.38 17.59 ± 9.10 17.76 ± 9.03 0.22 0.07 0.795 −0.60 2.41 0.121 −0.14 0.03 0.872 0.09 4.47 0.035
AI/N 12.30 ± 6.23 13.72 ± 7.95 10.33 ± 5.52 10.91 ± 6.07 0.98 2.28 0.132 −1.97 74.12 0.000 −0.85 2.34 0.127 0.09 9.83 0.002
AWI/REM 3.49 ± 3.78 3.66 ± 3.33 3.58 ± 3.69 3.75 ± 3.46 0.16 0.25 0.620 0.09 0.24 0.624 −0.01 0.00 0.985 0.06 13.94 0.000

5
AWI/N 3.90 ± 1.78 4.37 ± 2.20 3.38 ± 1.76 3.68 ± 1.89 0.38 4.67 0.031 −0.52 39.24 0.000 −0.16 0.73 0.393 0.05 39.06 0.000
Multivariate statistics 0.76 0.000 0.91 0.000 0.96 0.019 0.96 0.006
(Wilk’s Lambda)
Relaxation Evening 3.80 ± 0.77 3.22 ± 0.90 3.84 ± 0.81 3.48 ± 0.80 −0.47 36.28 0.000 0.04 9.19 0.003 0.21 4.61 0.033 0.00 0.34 0.560
Em.Balance Evening 3.87 ± 0.78 3.47 ± 0.87 3.93 ± 0.83 3.45 ± 0.91 −0.44 29.63 0.000 0.06 0.19 0.662 −0.07 0.47 0.492 0.01 3.54 0.061
Relaxation M-E −0.09 ± 0.91 −0.49 ± 1.12 −0.01 ± 0.90 −0.39 ± 0.90 −0.39 22.23 0.000 0.08 1.71 0.192 0.02 0.02 0.892 0.00 1.65 0.200
Em.Balance M-E −0.10 ± 0.85 −0.47 ± 1.04 0.01 ± 0.81 −0.16 ± 0.95 −0.27 11.06 0.001 0.11 10.53 0.001 0.20 2.55 0.111 0.01 3.16 0.077

For the Group effect, B=ID-GSC. For the Night effect, B=Night 2 - Night 1. p values below p = 0.05 are set in bold font.

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PSG and Emotional Parameters in Insomnia
Feige et al.
Target Variables (Relaxation and Emotional
Balance)
For the target variables (lower part of Table 2), all multivariate
effects are significant. Patients with ID show reductions in
all four variables (relaxation and emotional balance, both
evening values and differences morning-evening). In the
second night, relaxation in the evening and the emotional
balance difference morning-evening are increased. As evidenced
by the NIGHT x GROUP effect, the increase in evening
relaxation across nights was significantly higher in ID patients.
Finally, age tended to increase both emotional balance in
the evening and its morning-evening difference, not reaching
significance.
Between-Subject Effects
Table 3 shows the between-subject relationships between the
target variables and PSG, i.e., whether subjects with different
sleep characteristics tend to also show different values on
relaxation and emotional balance. Multivariate significance is
seen for evening relaxation and the evening relaxation x GROUP
interaction. Subjects with larger evening relaxation show reduced
SOL and increased TST, SEI, and stage N3 % SPT. Patients with
larger evening relaxation show reduced NWP and awakening
index in NREM sleep (AW/N) relative to the control group.
Figures 1, 2 show the relationship between evening relaxation
and SEI as well as NWP, respectively.
Within-Subject Effects
Table 4 shows the within-subject relationships between the
target variables and PSG, i.e., whether nights with different
sleep characteristics within the same subject tend to show
different values on relaxation and emotional balance. This
is generally more valuable than between-subject effects, since
possible different response tendencies across subjects are factored
out and within-subject effects are more suitable to predict
treatment effects.
Across groups, relaxation in the evening was strongly related
to within-subject PSG sleep quality: Reduced SOL, increased
TST and SEI as well as REM % SPT and REM latency (REML)
and a reduced arousal index in NREM sleep were related to
increased evening relaxation. The awakening index in REM
sleep was, surprisingly, slightly positively related to evening
relaxation.
Unexpectedly, the influence of the Morning-Evening
relaxation difference is for the most part of opposite direction
to the evening value, albeit with lower amplitude. This indicates
that evening relaxation is more important than morning
relaxation; with the scores limited between 1 and 5, a positive
Morning-Evening difference can only be attained if the evening
relaxation value is less than 5, associated with a negative impact
on sleep quality. Figure 3 shows these relationships graphically
for the example of SEI.
No other main effects or interactions reached significance,
particularly no relationship could be found between
the scales of emotional balance and any PSG sleep
parameter.
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PSG and Emotional Parameters in Insomnia
DISCUSSION
In the current study, we reported an extensive multivariate
analysis of the relationship between relaxation and emotional
balance in a large population of patients with insomnia and
matched healthy controls.
The level of relaxation, particularly in the evening, was found
to enhance sleep both between subjects and within subjects. This
suggests that relaxation can be an important therapeutic target
for treating sleep problems.
A single significant group interaction was identified: Evening
relaxation reduced the number of wake periods and, specifically,
the awakening index in NREM sleep more strongly in
patients with insomnia disorder. In fact, relaxation techniques
are important components in current cognitive-behavioral
treatments for insomnia (CBT-I, Trauer et al., 2015; Riemann
et al., 2017a,b; Friedrich and Schlarb, 2018), although clearly
only responsible for part of its therapeutic efficacy (Norell-Clarke
et al., 2015). Bertisch et al. (2012) have found that relaxation
techniques are generally under-used for sleep problems in the
general population. However, the therapeutic effect of relaxation
alone may not be sustainable, requiring other components of
CBT-I for a lasting effect.
The level of emotional balance as assessed by the SF-
A could not be linked to objective sleep parameters in this
multivariate analysis. This is interesting by and of itself, as ID
patients showed clearly reduced levels of emotional balance as a
group, an effect which has been partialled out of the emotional
balance—PSG relationships in our analysis. Therefore, the
finding means that, within each group, differences in emotional
balance were related to PSG parameters neither between- nor
within subjects. It is well-known that emotional reactivity is
impaired in insomnia, as well as some aspects of emotional
valence (sleep in good sleepers being distinguished by increased
positive but not necessarily reduced negative emotions; Baglioni
et al., 2010). Since these were group studies comparing insomnia
patients to good sleepers and the current study found clear
group differences in SF-A emotional balance as well, it may
still be that the latter construct captures the deficiencies in
emotional processing characteristic to insomnia to some degree.
In this case the current finding could be extended to emotional
reactivity and valence as well. This in turn would indicate that
targeting emotional reactivity, valence or balance itself would
rather not present a viable therapeutic approach. Further studies
making this link explicit are, however, needed to support this
conclusion.
Generally, mutual relationships between sleep and emotions
have to be considered (Kahn et al., 2013). Complicating the
matter further, reappraisal processes may be involved (cf. Palmer
and Alfano, 2017), for example general dissatisfaction with sleep
leading to more negative responses to any sleep-related question.
This could be a potential mechanism for the more negative
judgments on both the relaxation and emotional balance scale in
ID patients (Table 3).
Wassing et al. (2016) reported that the overnight resolution of
emotional distress contributes to hyperarousal. They specifically
targeted shame. Overnight resolution of emotional distress
6 January 2019 | Volume 9 | Article 2712
 TABLE 3 | Between-subject effects of relaxation and emotional balance variables.

Between
Feige et al.

Evening Morning–Evening Evening x Group Morning–Evening x Group

Relaxation Emotional balance Relaxation Emotional balance Relaxation Emotional balance Relaxation Emotional balance

B F p B F p B F p B F p B F p B F p B F p B F p

Multivariate statistics 0.92 0.049 0.92 0.064 0.98 0.963 0.95 0.405 0.90 0.014 0.95 0.407 0.95 0.389 0.94 0.211
(Wilk’s Lambda)
SOL (min) −20.44 10.66 0.001 13.99 0.05 0.829 −11.51 0.14 0.708 −2.10 1.46 0.227 −13.53 1.72 0.191 12.73 0.19 0.665 −4.89 1.44 0.231 22.86 0.30 0.584
TST (min) 32.15 8.28 0.004 −20.01 1.68 0.195 −4.63 1.14 0.287 34.51 0.59 0.443 62.94 0.97 0.325 −57.56 3.63 0.058 67.81 0.28 0.597 −58.81 0.22 0.639

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SEI (%) 6.13 7.87 0.005 −4.58 1.53 0.218 −1.05 1.17 0.281 6.91 0.48 0.490 13.94 0.76 0.383 −11.13 3.82 0.052 13.96 0.33 0.568 −11.54 0.28 0.597
NWP −0.82 0.08 0.779 13.46 0.00 0.945 3.04 0.10 0.747 3.35 0.03 0.854 −11.95 5.59 0.019 −12.59 5.17 0.024 −12.42 1.93 0.165 −2.95 0.02 0.896
W (%SPT) −0.64 2.90 0.089 −0.08 1.47 0.226 3.61 1.50 0.222 −8.71 0.20 0.653 −11.74 0.16 0.691 9.21 4.45 0.036 −12.63 0.07 0.793 9.63 1.95 0.164
N1 (%SPT) −2.07 2.52 0.113 0.66 0.34 0.558 2.08 0.01 0.926 −2.05 0.02 0.879 1.17 1.96 0.162 −1.38 0.86 0.356 −2.99 1.57 0.212 0.55 1.84 0.176
N2 (%SPT) −3.82 0.01 0.909 −2.56 0.26 0.613 −5.35 0.65 0.422 0.11 6.14 0.014 11.26 0.03 0.860 −5.49 6.95 0.009 14.06 0.03 0.868 −4.23 0.12 0.728
N3 (%SPT) 3.47 5.85 0.016 1.01 0.91 0.340 1.02 0.10 0.747 5.53 6.70 0.010 −2.04 1.58 0.210 3.15 0.23 0.633 −2.11 1.45 0.230 −2.98 0.01 0.921
REM (%SPT) 2.66 1.61 0.205 0.81 0.04 0.843 −1.30 0.84 0.360 4.26 0.02 0.892 1.42 0.61 0.434 −4.96 0.37 0.545 3.43 0.06 0.806 −1.94 0.28 0.597
REML (min) 8.77 0.71 0.401 −29.24 1.88 0.171 −9.95 0.53 0.468 −15.46 0.09 0.763 −40.13 2.23 0.137 39.68 0.16 0.687 −23.79 0.98 0.324 −6.26 1.23 0.268
REMD (%) −10.69 0.51 0.475 3.31 2.89 0.090 −9.03 0.75 0.386 3.30 0.14 0.712 4.59 2.76 0.098 −9.80 0.40 0.530 2.11 1.31 0.252 −2.11 0.16 0.691
AI/REM −3.80 1.19 0.276 5.89 0.33 0.566 −5.26 0.00 0.954 8.23 0.23 0.630 11.28 0.83 0.364 −3.03 0.49 0.483 8.18 1.58 0.210 −10.00 0.03 0.873
AI/N −2.90 0.18 0.673 5.04 9.32 0.002 0.22 0.57 0.452 −0.39 0.07 0.797 −7.50 1.35 0.246 3.15 3.09 0.080 −4.57 2.53 0.113 −3.14 0.02 0.888

7
AWI/REM 0.83 0.45 0.504 2.87 2.40 0.122 0.40 0.04 0.845 0.97 0.02 0.887 −1.70 0.64 0.423 −2.86 2.35 0.126 −0.66 0.16 0.689 0.34 0.01 0.908
AWI/N −0.86 0.12 0.730 1.87 0.87 0.353 0.25 0.50 0.481 −0.02 0.45 0.502 −1.72 4.31 0.039 −1.07 4.03 0.046 −2.11 1.26 0.262 0.26 0.00 0.988

p values below p = 0.05 are set in bold font.

January 2019 | Volume 9 | Article 2712

PSG and Emotional Parameters in Insomnia
Feige et al. PSG and Emotional Parameters in Insomnia

Night A Night B

100
90

90
80

80
70
SEI

SEI

70
60

60
50
40

50
GSC GSC
ID ID
30

1 2 3 4 5 1 2 3 4 5

Evening relaxation Evening relaxation

FIGURE 1 | Relationship between evening relaxation and SEI (%) for the two groups in first (Left) and second (Right) nights.

Night A Night B

GSC GSC
ID ID
80
80

60
60
NW P

NW P

40
40

20
20

0
0

1 2 3 4 5 1 2 3 4 5

Evening relaxation Evening relaxation

FIGURE 2 | Relationship between evening relaxation and NWP for the two groups in first (Left) and second (Right) nights.

means an amelioration of values during sleep (positive Morning-
Evening difference in our study). We did not see an influence
of emotional balance (or its difference across the night) on
sleep parameters, but a measure of (inverse) hyperarousal (i.e.,
relaxation) was included in the same model and apparently
correlated better with objective sleep parameters than emotional
balance itself. Thus, for the SF-A emotional balance construct it
appears that its change across the night is rather not related to
hyperarousal or objective sleep parameters. Since there is a clear
group difference in emotional balance, it is possible that impaired
emotional balance over longer periods of time (e.g., weeks) leads
to increased hyperarousal. This notion cannot be tested using
the data of the current study but should be addressed by future
studies.
In summary, in the current study we could separately assess
state- and trait- like influences of two emotional parameters,
relaxation and emotional balance, on PSG in large matched
samples of patients with ID and good sleeper controls.
While both parameters were lower in ID patients (“trait”),
particularly increased evening relaxation had a strong within-
subject influence on PSG sleep quality as a main effect across
both groups and was additionally linked to a reduced number
of wake periods in the ID patients, suggesting relaxation as
a useful therapeutic target in conjunction with other CBT-I
elements.
LIMITATIONS
While interpreting the results of this study some limitations
should be taken into account. First of all we used pre-existing
data which on the one hand lead to a large sample size but
on the other hand restricted the measurement of the emotional
state to two subjective items without defined valence. To assess

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 TABLE 4 | Within-subject effects of relaxation and emotional balance variables.
Feige et al.

Within

Evening Morning–Evening Evening x Group Morning–Evening x Group

Relaxation Emotional balance Relaxation Emotional balance Relaxation Emotional balance Relaxation Emotional balance

B F p B F p B F p B F p B F p B F p B F p B F p

Multivariate 0.84 0.000 0.96 0.608 0.78 0.000 0.94 0.216 0.94 0.209 0.95 0.476 0.95 0.369 0.95 0.541
statistics (Wilk’s
Lambda)

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SOL (min) −7.48 15.25 0.000 1.69 2.38 0.124 1.53 6.91 0.009 −2.92 0.58 0.445 2.78 1.39 0.240 0.93 1.42 0.234 1.60 0.70 0.404 7.48 0.89 0.345
TST (min) 17.49 12.08 0.001 −1.14 2.56 0.111 −2.66 29.05 0.000 8.90 4.55 0.034 6.47 3.90 0.049 −28.64 1.21 0.272 7.87 2.90 0.090 −12.99 0.15 0.699
SEI (%) 3.24 12.06 0.001 0.05 2.50 0.115 −0.93 31.70 0.000 2.11 4.47 0.035 2.22 3.51 0.062 −6.45 1.76 0.186 2.00 3.35 0.068 −3.02 0.13 0.718
NWP 0.08 0.09 0.771 −0.86 0.02 0.895 3.96 8.72 0.003 −5.38 1.70 0.194 −4.80 0.76 0.384 5.77 0.44 0.509 −9.67 1.50 0.222 6.99 1.89 0.170
W (%SPT) −0.68 3.04 0.082 −1.12 0.79 0.375 1.24 33.53 0.000 −2.48 0.96 0.329 −5.90 3.35 0.068 9.40 0.07 0.785 −4.16 4.42 0.036 3.78 0.85 0.358
N1 (%SPT) −1.00 10.62 0.001 2.03 0.15 0.699 0.05 4.30 0.039 0.46 2.74 0.099 −0.29 1.39 0.240 −1.21 0.73 0.392 −1.03 1.72 0.190 0.62 3.31 0.070
N2 (%SPT) 2.56 3.07 0.081 −0.78 1.57 0.212 −0.32 26.12 0.000 0.28 0.04 0.844 2.89 2.75 0.098 −4.40 0.38 0.541 4.11 1.07 0.302 −2.25 0.10 0.751
N3 (%SPT) −1.70 0.00 0.999 0.46 0.60 0.438 −0.37 5.72 0.017 1.84 0.94 0.334 2.64 1.07 0.302 −1.64 0.01 0.910 0.35 0.32 0.573 −1.58 0.07 0.798
REM (%SPT) 0.37 8.54 0.004 −0.15 0.60 0.439 −0.82 7.85 0.005 0.07 2.50 0.115 1.00 6.35 0.012 −2.58 1.37 0.244 0.90 8.55 0.004 −0.73 0.46 0.499
REML (min) 7.36 10.28 0.001 −5.38 0.03 0.869 18.87 16.62 0.000 −16.70 2.11 0.147 −49.62 2.69 0.102 30.47 0.82 0.365 −12.41 4.59 0.033 8.09 0.02 0.885
REMD (%) −2.33 3.86 0.050 −0.19 1.34 0.248 −0.55 0.15 0.696 2.65 0.43 0.510 2.43 0.71 0.400 2.74 1.04 0.309 1.39 4.16 0.042 −3.00 0.73 0.394

9
AI/REM 4.25 1.23 0.268 −1.85 0.00 0.975 −0.06 0.03 0.858 −0.30 0.36 0.551 −7.13 0.11 0.738 4.27 0.00 0.979 −2.65 0.37 0.541 3.48 0.54 0.465
AI/N −1.10 20.80 0.000 0.46 2.37 0.125 0.19 14.21 0.000 −1.41 1.46 0.228 −3.28 1.21 0.272 3.04 0.11 0.737 −0.74 5.22 0.023 0.84 0.00 0.997
AWI/REM 2.20 3.94 0.048 −1.65 0.71 0.400 1.53 2.82 0.094 −0.80 0.21 0.648 −1.89 0.20 0.657 2.05 0.00 0.994 −1.55 1.34 0.248 1.15 0.17 0.682
AWI/N −0.36 3.69 0.056 0.07 0.21 0.651 0.43 17.06 0.000 −0.58 1.50 0.221 −0.53 4.06 0.045 0.86 0.07 0.790 −1.30 0.76 0.385 1.01 3.03 0.083

p values below p = 0.05 are set in bold font.

January 2019 | Volume 9 | Article 2712

PSG and Emotional Parameters in Insomnia
Feige et al. PSG and Emotional Parameters in Insomnia

60

60

60
GSC GSC GS C
ID ID ID
40

40

40
SEI night diff erence

SEI night diff erence

SEI night diff erence

20

20

20
0

0
−20

−20

−20
−3 −2 −1 0 1 2 3 −3 −2 −1 0 1 2 3 −6 −4 −2 0 2 4

Ev ening relaxation night diff erence Morning relaxation night diff erence Morning−Ev ening relaxation night diff erence

FIGURE 3 | Within-subject relationships to the SEI captured as differences between nights: Evening (Left), Morning (Middle), and Morning-Evening (Right) relaxation.

the emotional state more broadly, another procedure should chronotype have not been assessed systematically for all subjects
be chosen in future studies. Buysse et al. (2007) presented although these characteristics could be related to potential
a possible procedure that additionally avoids ground effects. subgroup-differences and should therefore be assessed in future
Furthermore the evening data as used here was assessed in studies.
the following morning and could therefore be influenced by
the morning emotional state. To avoid such bias future studies ETHICS STATEMENT
should assess the emotional state in the actual evening. Possibly,
more questionnaires for sample description would have been The current study is a retrospective analysis of studies
useful. carried out in accordance with the recommendations of
Just like in every other sleep laboratory study the ecological the ethics committee of the University of Freiburg Medical
validity of the results can be questioned. The time needed for Center with written informed consent from all subjects. All
adjustment to the changed sleep environment is not known subjects gave written informed consent in accordance with
exactly, although an adaption phase of one night is usually the Declaration of Helsinki. The protocol was approved by
assumed (Le Bon et al., 2001). Since good signal quality and the ethics committee of the University of Freiburg Medical
monitoring options are still lacking for the home environment, Center.
sleep laboratory data in general may lack ecological validity.
This is, however, partially true also for sleep studies conducted AUTHOR CONTRIBUTIONS
at home, because the presence of the recording equipment is a
factor in the “First Night Effect” as well (Blackwell et al., 2017). BF and DR devised the study. BF devised the data analysis,
In the current study we analyzed both between- and within- interpreted the data and wrote the manuscript. BB and DM
subject influences between PSG and emotional parameters. analyzed and interpreted the data. All authors contributed to the
The “First Night Effect” generates welcome within-subject manuscript.
variability in this respect (it can be interpreted as a “stress
probe” for sleep). Part of our within-subject results could be FUNDING
due to this special situation with an unusually disturbed first
night. The article processing charge was funded by the German
Finally, most of our data has been collected during clinical Research Foundation (DFG) and the University of Freiburg in
routine. Therefore characteristics like personality traits or the funding programme Open Access Publishing.

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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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11 January 2019 | Volume 9 | Article 2712